How Public Health Fared on the Ballot in 2016

On Tuesday, voters across the country had the opportunity to influence state policy through ballot initiatives on key public health issues like marijuana use, tobacco taxes, and health system reform. While official results are a few weeks away, the preliminary results are in.

Tobacco tax initiatives were less successful: only California’s Proposition 56 passed, raising the state’s tobacco taxes from $0.87 to $2.87 per pack.

California also appears to have passed the only healthcare reform ballot measure.Proposition 52 restricts the use of the Healthcare Quality Assurance Fee to support the Medi-Cal program and repeals the fee’s sunset date.

Marijuana Measures

With the most recent ballot initiatives, over 50 percent of the U.S. population now live in a jurisdiction that permits medical marijuana, while 20 percent live in a jurisdiction that allows individuals over 21 to use, possess, and buy marijuana. On Nov. 8, California, Massachusetts, and Nevada passed retail initiatives (the results in Maine are too close to call); Arkansas, Florida, and North Dakota passed measures allowing medical marijuana; and Montana passed a measure to amend its medical marijuana program.

In California, Proposition 64 allows individuals over 21 to possess up to 28.5 grams of marijuana and up to eight grams of concentrated marijuana. Individuals may also grow up to six plants. The initiative also allows regulated retail sales through the Bureau of Marijuana Control (formerly the Bureau of Medical Cannabis Regulation). The state will impose a 15 percent tax on marijuana sales, a $2.75 per ounce cultivation tax on leaves, and a $9.25 per ounce cultivation tax on flowers. The California Marijuana Fund will collect the tax revenue to cover the cost of implementing and enforcing the law. If funds remain, the state has allocated dollars for drug research, treatment, and enforcement. This includes $10 million in grants for local health departments and community-based nonprofits, with the potential to increase to $50 million over five years. Any remaining tax revenue will be allocated for youth education, environmental restoration, and public safety. Proposition 64 also prohibits marijuana use wherever tobacco is prohibited.

While results in Maine are still pending, Maine’s Question 1 would adults over 21 to use, possess, or transport up to 2.5 ounces of marijuana and to possess up to six plants. The Department of Agriculture is responsible for regulating retail marijuana sales, taxed at 10 percent, with revenue directed to the state’s general fund. The measure prohibits the use of marijuana sales tax for new state programs, except for programs to train law enforcement on the new marijuana measures.

Question 4 passed in Massachusetts, allowing individuals over 21 to possess up to one ounce of marijuana in public and up to 10 ounces in their homes. Individuals can also grow up to six plants. The measure creates the Cannabis Control Commission to regulate retail sales. Marijuana sales are subject to a 12 percent tax, with revenue placed in the Marijuana Regulation Fund to cover administrative and enforcement costs.

In Nevada, Question 2 allows individuals over 21 to possess up to one ounce of marijuana (or 1/8 ounce of concentrated marijuana) and grow up to six plants. Retail sales are regulated through the Nevada Department of Taxation, and the measure specifically restricts the number of retail licenses allowed in a given area based on the county’s population. Marijuana sales are taxed at 15 percent, to fund implementation and enforcement of the new measure and education.

All of the medical marijuana initiatives passed.

Arkansas Issue 6 amends the state constitution to allow patients with 12 specified medical conditions to use medical marijuana. The Alcoholic Beverage Control Division, the health department, and a new medical marijuana commission will regulate dispensaries and cultivation sites. Marijuana sales are subject to all state and local sales taxes, and the measure describes how tax revenue will be used, including five percent directed to the Arkansas Department of Health to operate a patient registry.

Florida’s Amendment 2 allows medical marijuana use by patients with specific medical conditions. It also permits state-licensed physicians to certify that a patient has “other debilitating medical conditions of the same kind or class or comparable” to the ten conditions enumerated in the measure. Patients who are certified by a physician can use medical marijuana for treatment.

Montana voters enacted two measures to modify the state’s medical marijuana law. I-182 increases the number of patients to whom licensed medical marijuana providers may dispense, eliminates a requirement for physicians who certify marijuana for more than 25 patients per year to undergo a state review, and allows chronic pain and PTSD to be treated with marijuana. I-172 requires the state to conduct annual inspections of marijuana facilities, but removes the ability of law enforcement to conduct unannounced inspections. I-172 also allows medical marijuana providers to hire employees.

In North Dakota, Initiated Statutory Measure 5 allows medical marijuana to be used to treat specific conditions. The measure allows patients to petition the health department to add to the list of conditions that may be treated with medical marijuana. The North Dakota Department of Health regulates cultivation and dispensing. The measure also allows patients to cultivate marijuana in their homes if they reside more than 40 miles away from the nearest dispensary.

Tobacco Tax Measures

The average state tax on cigarettes is $1.65 per pack. Voters in California, Colorado, Missouri, and North Dakota considered measures to increase tobacco taxes, but only California’s Proposition 56 passed, raising the tobacco tax from $0.87 per pack to $2.87. These taxes also apply to e-cigarettes. Tax revenue is dedicated to physician training, oral health, Medi-Cal, tobacco use prevention and reduction, including school-based programs and research on tobacco-related diseases. In addition to California, three states—Louisiana, Pennsylvania, and West Virginia—increased their tobacco taxes during the 2016 legislative session. In Colorado, Missouri, and North Dakota, the tax remains at $0.84, $0.17, and $0.44 per pack respectively.

Healthcare System Reform Measures

Ballot initiatives in California and Colorado also addressed healthcare reform and delivery. California had two propositions related to health systems. Voters rejected California Proposition 61, which would prohibit state agencies from paying more than the U.S. Department of Veterans Affairs for prescription drugs. However, Proposition 52 passed, restricting the legislature from diverting the Hospital Quality Assurance Fee from the state Medicaid program to the general fund, and continuing the fees beyond the January 1, 2018 sunset. Voters rejected Colorado Amendment 69 to establish a universal healthcare system financed through a payroll tax.

KT Kramer, JD, MHA is ASTHO’s director of state health policy. She supports state and territorial health agencies to advance and strengthen public health
through laws and policies.